Toe Amputation Recovery

Hey guys,

Last year I lost one digit of my big toe and two digits of my 'index' toe due to frostbite. Since then I have gradually recovered with walking and climbing, but with two big issues:

1. Body mechanics
2. Pain (the bigger problem)

I'm wondering if any fellow climbers have been in the same boat and have any advice?

For body mechanics, it seems fairly minor and is mostly fixed by wearing stiffer-soled shoes. Only in the most extreme cases, such as heel-toeing in an OW, or liebacking with this as my higher foot, do I seem to suffer. Apart from adjusting technique & expectations, I wonder if anyone has ideas of what might help? I've toyed with the idea of getting the shoes modified to better follow the shape of my foot, but that might load the middle toe too much. Or if prosthetic inserts might do me any good? (with a lack of real shear transfer into my foot, I am dubious).

For pain, I have noticed that I seem to improve slowly with desensitization by trying to stand more on the stumps, but progress has been slow and seems to regress easily when I am not working it regularly. I'm curious if anyone knows of some good exercises to do (esp. when not climbing) and perhaps what I can expect with recovery potential.

Currently I see liebacking and heel-toeing in OWs to be unbearably painful! I hope I can work out of it ...

My foot post-autoamputation and cleanup surgery.

Two thoughts, first, if you live in a big enough town, you should have a business that specializes in orthotic (is that the word?) shoes. Toes getting amputated is an unfortunate side issue of diabetes, so it is not uncommon. They might be able to literally cobble something up for you, that will work with your climbing shoes. And they should understand your toes, where the nerves are, what the pain issues could be, etc.

Second, I have no idea what triggers your pain, but I have arthritic knees, and capzaisin is helping quite a lot. I'm using the milder version, which also has menthol, and comes in a gel with a built in sponge applicator. It goes on twice a day, every day.

I would think strengthening all the other adjacent parts should help your feet, as it will my knees when I get to work on it. Those toes are connected surprisingly far up your foot, the nerves even more so. Have you asked your PT?

Hope you were at least doing something fun when you got the frost bite!

Best wishes, Helen

Sorry to hear that one went to market and the other one went home...

I met a lady who had lost toes on both feet to frostbite. She used custom shoe inserts - no idea about the pain management, though. I'm sure the stumps are pretty damn sensitive to pressure and direct contact. Perhaps acclimation to the pressure of climbing and wearing climbing shoes is the way to go?

Yes, my friend Mike Kirby lost his toes while on Longs and is now back to full send mode and is a guide for Exum. He does have an adorably small shoe for that foot. PM me your info and I'll get you in touch!

Old lady H wrote:Two thoughts, first, if you live in a big enough town, you should have a business that specializes in orthotic (is that the word?) shoes. Toes getting amputated is an unfortunate side issue of diabetes, so it is not uncommon. They might be able to literally cobble something up for you, that will work with your climbing shoes. And they should understand your toes, where the nerves are, what the pain issues could be, etc. Second, I have no idea what triggers your pain, but I have arthritic knees, and capzaisin is helping quite a lot. I'm using the milder version, which also has menthol, and comes in a gel with a built in sponge applicator. It goes on twice a day, every day. I would think strengthening all the other adjacent parts should help your feet, as it will my knees when I get to work on it. Those toes are connected surprisingly far up your foot, the nerves even more so. Have you asked your PT? Hope you were at least doing something fun when you got the frost bite! Best wishes, Helen

Yeah, I guess I meant orthotics rather than prosthetics! My bad. I have options for that (Bay Area), just not sure if they're helpful beyond walking. e.g. if the toe ramming on downhill hiking is still a problem for my smaller toes, I would definitely look at them for taking that axial load ... if I can get that pressure sensitivity down.

I've heard the diabetic amputations are caused initially by desensitization, so apparently they have my opposite problem as they can't feel their feet well enough to avoid damage! My sensitivity to pressure is the greatest on the outside edge of my big toe. There is a big bone horn there that had to be trimmed really far back, so I assume the edges are rougher and/or I have less tissue between the bone & skin there.

My doctors in the burn unit had no real interest in pain management, quality of life, or PT. I am doubling PT with an ankle ligament surgery I got this Fall (old injury that I lived with until the toe loss destabilized the foot more), but they didn't seem to know too much. I did talk with a foot surgeon who talked a bit about orthotics and my risks (or lack thereof) of continued hard activity on the altered foot, but my recovery to walking & climbing was early enough that I didn't quite have these issues known then.

As far as fun? Sort of. Not a climb where it was at all a consideration (perfect winter weather, lows in the mid-20s), nor one where 'it was worth it'. It was my second mountaineering climb after having 3 reconstructive knee surgeries 1-1.5 yrs prior, and I was scaling back from technical to more physical stuff out of fear that I was pushing my re-entry into climbing too fast. oops.

We climbed the E Ridge of Arrow Peak in the Sierra Nevada (center) in February 2015. Cl. 3 but simuling was nice in parts due to exposure and bottomless sugar snow. +10 miles & 7,000' of gain to get to the base, and farther than I'd have liked to walk out with the frostbitten foot! At least I kept the other toes and foot, as I was at risk of losing them from frostbite or resulting cellulitis.

When did you lose your toes?

February 2015, but it took until November for them to finish healing or falling off, with surgery in December. Took me until this July to get beyond total foot pain in the tarsals & metatarsals to walking into hiking shape, but with a lot of pain tolerance/persistence in the foot I knocked off +30 CO 14ers between then and the end of August :-) ... and a lot of the foot issues gradually worked out with that.

I just did bits of trad leading in January, March & August, and a bit of gym climbing - just enough to get a sense of limitations and some progression of sensitivity, but it seems like some of the pain issues there will be harder to surmount, and the desensitization seems to backslide if I am not climbing continuously enough, so knowing some 'dailies' to do at home or the office might be helpful.

Had all 10 of my toes removed in May, just now getting to where I can squeeze climbing shoes on.I have been on rock twice with no toes ,both times in mountaineering boots.I have been told that my best option will be my regular climbing shoe with a carbon orthotic and a toe filler.I am thinking an orthotic with a toe filler to take the place of the missing tissue might be the ticket for you.I am currently planning on orthotics for my street and climbing shoes as soon as a I can afford them.I was able to contact Ronnie Dickson via facebook (amputee climber and he makes prosthetics and orthotics, he also helped evolv develop their climbing foot for prosthetics.) it seems that he may be the most relevant source of info for you.He was the only individual I found that had any info.Good luck , if you happen to find any info, let me know.formulagreg@gmail.com.All the best, Greg.

Orthotics do nothing in a climbing shoe while climbing. Orthotics function when the mid-foot and heel are in contact with the ground - this is not the case when you're actually climbing. My first podiatrist made me some very nice and expensive orthotics for my climbing shoes because he didn't understand the mechanics of rock climbing. My second podiatrist confirmed that orthotics do nothing in this application. Instead, I have a rigid carbon fiber plate in my climbing shoe to reduce toe flex. I suffer from Hallux Rigidus, which is arthritis and stiffening of the big toe joint.

For general walking, a foot orthotic in addition to a carbon plate will likely be the best thing to help with toe off, but you have to have a good shoe that secures to your foot well, preferably mid top and lacing through the top and farthest "back" eyelets. I do not think you will gain much from a custom foot orthotic in a climbing shoe; better to downsize on that foot to get your remaining foot snug against the shoe. A higher-top climbing shoe will do more to give you more leverage holding the shoe to your foot. You can try to pair this with a carbon insert, but a smaller shoe that fits better to your skin is usually better than inserts or fillers, though this can depend on the type of amputation. Even consider buying completely different brands and styles of shoe for that foot.

Check this out for buying your own less expensive carbon inserts: wrymark.com/store/page6.html. This is the brand that we use when making foot orthotics for amputations and a number of other applications. Go middle of the line for flexibility/rigidity if picking your own, until you form an opinion on if you want more or less.

My best piece of advice is to do everything you can to de-sensitize. I am not familiar enough to weigh in on frostbite, but do massage and touch on the amputation every night. The more you can do to help the nerves re-wire to the brain and "understand" what is what, the better off you will be.

Take a vitamin B complex as well as E. Nerves rely on B, so I would definitely supplement that for about a year. Be aware that peripheral nerves do regrow, unlike the nerves in the spinal cord. They can develope balls or "neuromas" which can be painful. If you have a pinpoint area that is causing problems, be mindful of it and do not necessarily just "suck it up".

You may consider a custom foot orthotic with substantial unloading of the 1st Metatarsal head by means of a substantial metatarsal pad or even a full met bar. A podiatrist wont be able to customize this as well as an orthotist, so it depends on what you need.

In the long term, you may find yourself walking on the outside of your foot because this helps lock the bones of the midfoot by being in supination. Because you cant progress off your great toe as well, over the long haul you may find that you are cheating away from the inside of your foot. Do your best to walk evenly; desensitizing will help the most with this. If you cant walk evenly between the outside and inside edges of your foot, then pursue a custom foot orthotic from an orthotist with a cork base. THis will allow greater customization than a rigid laminated foot orthotic from a podiatrist.

Just my 2 cents, hope some of that helps!

A follow up as I have returned to activity this past year. This is from a response I have to someone inquiring about how his toe loss might affect him in some activities:

In a lot of ways I have found the toe loss hasn't limited me, but there have been some surprises where it affects me and I need to work through it in different ways. Some are easier to handle than others.

As time has gone on and my stumps have decreased in sensitivity, my main problem as been the overloading of the remaining toes. My middle toe sticks out a ways beyond the rest of the foot, and the three outside toes in general are far weaker than the inner two that I lost. This causes two problems:

1. Overloading of the other toes axially, or by crushing the outer side, when my foot presses forward in a shoe.
2. Overloading of the middle toe in bending, hurting the bone & joints.

Both of these limit me by pain, and #2 also limits me mechanically in motions that really require toe spring.

For #1, I am still working out strategies. One is that I might be getting an orthotic made with some ridges to catch my foot at the ball, and a filler that would abut against the stumps if the foot slides too far over the ridges. I went to a prosthetics outfit where they came up with this idea and made a demo they let me keep, and I can tell it helps. However, they estimate the cost to be about $500 to make one.

For #2, it seems like about the only things I can do to address it are modify my form slightly to not overload the middle toe (e.g. stop short of fully rolling through, or rolling/switching more to an outside edge), or to wear a shoe with a stiffer sole to better transfer the load directly to the ball of my foot and reduce the amount of bending at the toe tips.

In normal shoes, I do this just by looking for the ones that are made stiffer. For climbing I also put in some inserts that have steel plates that bridge from the ball of my foot to my toe tips. This still leaves me with enough spring, but helps to reduce force on the toes. Since I only need them on one side, I normally have the left insert flipped so that I can double them up.

http://www.healthyfeetstore.com/turf-toe-insoles-half-steel.html?cmp=googleproducts&kw=turf-toe-insoles-half-steel&Size=8%20-%20Men&gclid=CjwKCAjw2s_MBRA5EiwAmWIac0n0ZIsmTWSK3gfW-nJ0bVzptfi9J3AfK0QvBWqwiJwH7CZBcxzDSRoCrkIQAvD_BwE

These work well enough that I might consider spending more money for carbon fiber later, but at least for now these are great and cheap things to try out.

I doubt your golfing will be affected much, or at most by having a squishier toe to slide onto as you twist in your swing. This could easily be remedied by a stiffer shoe or inserts.

For baseball, similar deal for throwing if you kneel down deeply. For running, it's hard to say. I jog longer distances and with a 10 minute/mile pace I don't need to roll through my toes much. For an all out sprint, you might have some issues, as the roll through is affected and a stiffer shoe might begin to interfere with that?

Most of crossfit should be fine, especially if aided with shoes. e.g. I have no problem planking or doing pushups as long as I am not barefoot. However, 'mountain climbers' are very painful. So select exercises like that might need to be skipped or modified.

In case you are wondering about how it affects my main activities:

In hiking, it has no effect, except for hiking downhill, where my toes take much worse pounding, but this has been helped with technique (e.g. skating lunging forward to stay more on the balls of the foot), hiking down more slowly, taking care to step on more solid surfaces/rocks, side stepping or walking down at an angle/mini switchbacks, retightening shoes before descents, wearing the orthotics, and putting up with the pain until I develop better calluses. Getting out more helps. I slip and fall on my butt more on descents, though, as the center of pressure in my right foot is farther back to stay off the toes, so I am closer to tipping backwards when I slip and my right toes are less likely to dig into the soil as I start to slip. Naturally, I deal with this by recognizing when this might occur and slow down or walk more sideways. For steeper trails or scrambling, if I am too aggressive on the toe tips I slip more in the toe tip since it has more give, but it hasn't been a big deal, esp. if I remember to accommodate it having more give and hike keeping my heels down, or choosing different features to step on.

In cycling, the outside pinky toe still gets crushed badly, so I am trying to work out how to deal with that as after the first 30 miles or so of riding I need to take breaks to take off the shoes and let the toe expand. Maybe a shoe stretcher?

In climbing, heel-toeing on that foot is more slippery and painful when it is the outside leg. Liebacks with that foot as the inside leg is far weaker and very painful. In face/slab climbing, it slips more and hurts a lot more if I am on my toe tips. However this is reduced if I modify my position to smear more on the ball of my foot, or use an outside edge. Besides the steel plate I haven't seen a need to modify the shoe any for me to climb all types up to 5.9, or 5.10a & higher for cracks of any size. It seems like I am mostly getting by through developing better pain tolerance/thicker toe skin, and discovering minor technique adjustments to better offload the toes. I am returning to leading more slowly and carefully to avoid unexpected surprises with giving way or distractions from pain.

The steel plates also help in thin crack climbing as I can leave my shoe farther outside the crack and twist the empty shoe, reinforced by the place, to get my hold, rather than crushing the remaining toes while they are barely inserted.

Hi,
Im Jeff Porter. I am a disabled Navy Vet. I lost all my toes on my right foot and half my great toe left foot  I am a diabetic, but my A1c is 6.1. I have strong pulse and circulation in both feet. I also shattered my  Navicular bone in my left foot, causing charcot syndrome. I am currently wearing stirrup style braces and cork inserts and toe fillets. I can't  seem to do any fast walking. What can I do to increase flexibility and strength.y personal email is jerseydevil1965@gmail.com
 I appreciate any help. I am in Holiday Fl. Just North of Clearwater FL. Any ideas of a therapist would be a blessing. Thank you.